Midwifery Today is taking a break during the holiday season, so there will be no E-News published on December 22. The next issue will be sent on January 5, 2005. Have a wonderful holiday and a happy and healthy new year.

Midwifery Today Conferences

Want to learn about second stage, hemorrhage or how to improve your practice? Or are you more interested in herbs or the Rebozo? Whatever your focus, you'll find classes of interest at the Midwifery Today conference in Denmark, May 2005.Plan now to attend.

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Quote of the Week

"Crowning is the part of birth when baby is between two worlds."

— Denise Punger

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The Art of Midwifery

I have used arnica gel successfully on an edematous cervix (cervical lip). An exam glove finger filled with ice works well too.

— Marlene Waechter, Midwifery Today Forums

ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.

Research to Remember

The relative risk of new mothers developing persistent urinary incontinence was 2.8 at one year following forceps delivery and 0.8 following vacuum delivery, compared with the risk of incontinence following spontaneous delivery, according to a study of 315 women. Of the group, 150 had spontaneous delivery, 90 had forceps assistance, and 75 had vacuum extraction. The rate of incontinence at two weeks postpartum was 13.3% in the vaginal delivery and vacuum extraction groups and 12.2% in the forceps group. The rate at three months postpartum was 6.8% and 6.7% in the vaginal and vacuum groups, respectively, and 12.5% in the forceps group. The trend continued for one year postpartum, with 3.7% in the spontaneous vaginal group and 2.8% in the vacuum group, compared with 9.8% in the forceps group.

— OB/GYN News, April 15, 2001

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The Prenatal Clinic and Procedure

Preparing in advance for the prenatal clinic visit lets your clients know you value their time and want the visit to be as profitable for them as possible. Before the couple arrives, review the chart and calculate the number of weeks the pregnancy has progressed. Think through what you will expect to find when you do the physical exam. Read your notes from the previous visit to see if you need to follow up on anything.

Give your undivided attention to the visit. Let your answering machine pick up phone messages silently. Keep office interactions with staff brief. Take time to explain every unusual finding and its significance in the overall picture of the pregnancy, but avoid the temptation to tell long-winded stories to illustrate your points. Let clients have lots of time to talk and express their concerns and questions.

Engender a secure feeling of privacy during the clinic visit. People waiting for the next appointment should not be able to overhear your conversations with clients. Don't discuss any of your other clients' births or circumstances. Professional practice includes a mature, refined way of speaking that keeps things brief, to the point, and in good taste.

Ask a friend to critique your clinic environment occasionally. An outsider is better able to assess things than the person who is working all day long in that environment.

Keep asking yourself, "What would take my clinic to the next level of excellence?" Ideas for a higher level of professionalism include:

While I fully support the philosophy that the baby and mother are physiologically one being, there are still two consciousnesses to consider when you provide care. As the baby moves from the spiritual world into its physical body it becomes more and more aware of external influences as the pregnancy advances. This is reflected by the baby's increasing ability to see, hear and respond to outside stimuli. As the midwife, you will be one of the people with whom the baby will develop a consistent relationship prior to birth.

From the onset of care, whenever I come into contact with the baby, I talk to the baby about what I am doing, how it is growing, what position it needs to be in, etc. I give the baby positive verbal feedback to get it used to the sound of my voice, to let it know what is happening, and so that, in the event of a problem during the birth, we have already established a relationship. This lets the baby know that such activities as palpation and listening for heart tones are not just random pokes from the big world outside but are due to the care and interest of a particular individual. If a problem arises during prenatal care, I tell the baby what is needed (for example, it is easiest to come out head first). If the baby won't cooperate, I consider that the baby may be trying to tell me something and proceed from there (perhaps the cord is around the neck, making it, in fact, easier to be breech).

I have found that it sets up a psychic connection with the baby to relate to it as a sentient and sensitive being right from the start. I feel much more in tune throughout the pregnancy, the labor and the birth and have had experiences that bear this out. Try it and explore your own experiences in this light.

Editor's Note: Readers, E-News invites experiences and comments about Anne Frye's technique. What are your methods for "getting to know" the baby and building a relationship with the baby in utero? How has it affected the births you have attended?

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Forum Talk

I am wondering about a homebirth. My husband is concerned because my first baby was a c-section and has heard all the stuff about VBAC and rupture. He is a very logical, prove-it sort of fellow. I can't just say I've heard this or that. Does anyone have some specific articles that I can have him read to help him make a more educated decision this time around? I sure would appreciate it!

— Anon.

Go to our forums to share your thoughts and experience.

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Question of the Week

Q: Since giving birth, my hair has thinned to a tenth of its normal thickness. I had a normal birth, with no hemorrhage. Does anyone have suggestions how to stop my hair from falling out?

— JSC

SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.

Question of the Week Responses

Q: What do you do when you don't have a last menstrual period to track the conception date? I had a tubal pregnancy. After a D&C it was determined that I would need either tubal surgery or Methotrexate. I chose Methotrexate because I didn't want to have part of my tube removed. Subsequent to the Methotrexate, I was getting blood samples taken to confirm that the HCG levels were going down, and they were.

While waiting for my period so that I could start oral contraceptives, the condom broke, and I've been waiting for my period. It's late—I think. I was just getting my cycle back from 10 months breastfeeding so it wasn't regular. If I'm pregnant, what do I do? How can I determine my due date?

— Catherine Sutton

A: An ultrasound will give a very accurate EDC if done in the first trimester.

— Julie, CNM

A: Sounds to me like if "the condom broke" is how the pregnancy occurred, that's the date I would look at for conception. I don't know the other dates involved or how far apart they are, but it sounds like Catherine knows the earliest "not possible" date, the date of the D&C/Methotrexate procedure. She knows her period is "late," so there's another maybe date to look at. And if there's the slightest possibility that she would have had a fraternal twin pregnancy that the Methotrexate did NOT abort, that should be considered.

Bottom line is that although I'm really not a pro-ultrasound midwife, I'd be tempted in this case to have one, partly to make sure there wasn't a second embryo initially, and partly to see the developmental age of the current pregnancy, if any.

— Kerry Kraft, St. Helens, OR

Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.

Feedback

I had a natural waterbirth that went very well. In the final stage as my daughter's head came out, the midwife saw that the umbilical cord was wrapped very tightly around the baby's neck; it could not even be slipped over her head. My daughter could not come out any farther because the cord pulled tighter around her neck. The midwife then said that she would have to cut the cord there and then, which she did.

After the birth, I have read numerous articles about early cord clamping and the complications that it can cause. I saw the Web site address on your most recent issue of E-News about cord clamping. My daughter is five and a half months old now and is doing very well, with all milestones achieved just before or on the required months. I must admit having her cord cut not even as she was out did concern me very much; however, getting her out healthy was obviously the most important. Do you think there was any alternative or was that the best thing to do? I just would like to know as a matter of interest.

— Leanne, South Africa

Regarding Denise Allen's questions regarding her son's cerebral palsy as it relates to birth trauma [Feedback, Issue 6:24], I would recommend consulting [the book] Williams Obstetrics as a starting point. It discusses breech birth and cerebral palsy directly, and it also extensively covers CP as it relates to birth trauma. It also cites several studies within the past 25 years that support its opinions, which Denise may want to access. She could also go to her closest university library and have a qualified librarian help her do a literature search on the Cochrane Database and others for more recent research going on in this area.

It is fantastic that she is trying to find out more about the possible causes of her son's CP, as "science" is not always fact, but sometimes myth, anecdotal, or opinion. At the same time, the relationship between CP and birth trauma is not well supported in the literature. The literature does support that there are higher rates of CP with persistent breech babies regardless of mode of delivery (vaginal or c-section), and that CP is most often related to the brain and congenital issues rather than neck or spinal trauma.

In response to the aggressiveness of your obstetrician in getting your baby's head through the uterine incision, I too have seen physicians do the same. While I don't defend wanton physician roughness, it is possible your provider was simply trying to get baby's head out as soon as possible. Cutting a larger incision at the time the baby's head is stuck is not easy, and there is great risk of cutting the baby, so I can understand what you perceived as roughness may have simply been prudence on their part. In the hospital where I practice, we usually do c-sections for breech at 37–39 weeks, possibly to avoid problems with trapping in the incision and to avoid cord prolapse should mom's bag of waters break before surgery. In reference to your question about injuring the baby through the incision, I think the risk the literature refers to is more that of nicking the baby with the scalpel used to open the uterus more than it refers to trauma caused to the baby when bringing it through the incision.

— Kari, BSN, RN, nurse-midwifery student

We know that RhoGAM has been thimerosol free since 2001, so why the drama about calculating the "mercury dosage" from a RhoGAM injection [Issue 6:24]? This information is no longer valid to my knowledge.

— Susan Murphy Cohen, CNM

I want to start training as a midwife in America, but I am living in the UK. Please let me know if I can meet my dream and study in America and move there as a student. I am also getting married to an America resident, so what do I need to do?

— JHA

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mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.

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